Conquering Medial Tibial Stress Syndrome

By John T. Hester, DPM, MSPT

   Institute ice and NSAIDs (for pain control) early on in treatment. If symptoms are present even with daily activities, patients can use a cast boot or pneumatic leg splint for two to four weeks. Physical therapy is a key component of treatment and may include soft tissue management, massage, electric stimulation, ultrasound or iontophoresis. Some clinicians have used bone growth stimulators (electric, pulsed electromagnetic fields or ultrasonic) on tibial stress injuries in athletes. However, keep in mind that the only randomized controlled trial that evaluated the effect of bone stimulators on TSF in athletes found no difference in healing times.17

   Cold laser treatment is a relatively new option although it is largely unproven. Acupuncture is another alternative treatment for particularly refractory or painful cases. Surgery for chronic, refractory cases of MTSS is an option although results are variable at best. Performing a release of the fascial attachments to the posteromedial tibial margin has had reported success rates of 29 to 86 percent.17 However, a recent study reported that only 41 percent of athletes returned to pre-surgery levels of participation.18 There is also an interesting case study describing a college athlete who was able to get through her soccer season following a sympathetic block for refractory MTSS.19

Emphasizing Preventive Measures

   Long-term management of MTSS is centered on prevention. Eliminating training errors is the cornerstone of preventing MTSS. Doing “too much too soon” at the start of a training program or sports season is the most common training error scenario. The highest incidence of bone stress injuries occur in the first month, which corresponds to the most porous phase of the bone remodeling cycle.9

   Practitioners also need to address surface and terrain issues. Grass, sand and road shoulders are not universally preferable to road running due to their irregular surfaces. A level uniform surface of moderate firmness is optimal for minimizing injury risk.15 Shoes should be sport-specific and patients should change running shoes every 250 to 300 miles. Studies have shown that a running shoe may lose greater than 60 percent of its shock-absorbing capacity after as little as 250 miles.3,20

   Establishing normal strength, endurance and flexibility of calf and leg musculature is also important. A tight or overly strong triceps surae can impart an increased bending moment on the tibia. Weak or fatigued leg muscles may also result in up to a 25 percent increase in ground reactive forces.9

   One should also address biomechanical abnormalities and structural malalignments but keep in mind that investigators have found few statistical relationships between alignment measures and overuse injuries. However, two recent studies do support an association between excessive subtalar joint pronation and MTSS in runners.5,7

   Finally, do not overlook hormonal and nutritional factors. The female athlete triad (amenorrhea, disordered eating and osteoporosis) has been linked to decreased bone marrow density and increased risk for bone stress injuries.15 It is important to note that the female athlete triad is not limited to elite athletes and that many athletes with these issues will not always meet the classic definitions or criteria.16

   Nutritional assessments and diet counseling may be indicated even for athletes without disordered eating. Insufficient protein or calcium intake relative to the caloric demands of the athlete’s specific activity may be present.16

When Athletes Can Return To Activity

   The return to activity for athletes after treatment for MTSS must be gradual and individualized. Athletes must adhere to the “start low and go slow” mantra. Once athletes are asymptomatic, they can typically start at 50 percent of their baseline training load and increase the frequency/intensity/duration by 10 to 15 percent per week. They should avoid back-to-back days of repetitive impact activity for the first two to four weeks, depending on the severity of the case.


Excellent Resource. Offers great clarity for this often misdiagnosed malady.

very good article.

Yes, this was a very good article. Very informative. Thank you.

Add new comment